Myocardial Ischemia In Children Research Articles

Лайм-кардит у підлітка (клінічний випадок)

In recent years, the number of registered cases of Lyme carditis has been increasing. Purpose - to increase the vigilance of clinicians in various fields of medicine regarding Lyme carditis and awareness of its clinical manifestations on the example of the following clinical case. An empirical, descriptive study of a clinical case of Lyme pericarditis in a child from an endemic area was conducted. The research was carried out in accordance with the principles of the Declaration of Helsinki. The research protocol was approved by the bioethical commission of the hospital. Patient consent was obtained. An analysis of the literature data of PubMed, Medscape, СDC was also carried out. Clinical case. The paper describes a clinical case of a teenager with manifestations of pericarditis as a complication of Lyme infection with manifestations of untreated erythema migrans several months after a tick bite. The appointment of non-steroidal anti-inflammatory drugs did not bring relief. Conclusions. Alertness to Lyme carditis is important in the diagnosis of infectious nosologies. Lyme carditis should be considered in the differential diagnosis in patients with signs of myocardial ischemia in children with bradycardia living in endemic areas. For differential diagnosis, a two-step serological blood test is required, especially the use of screening tests for antibodies to Borrelia by ELISA with further confirmation by Western blot analysis. The research was carried out in accordance with the principles of the Helsinki Declaration. The study protocol was approved by the Local Ethics Committee of the participating institution. The informed consent of the patient was obtained for conducting the studies. No conflict of interests was declared by the authors.

5597164 BURDEN AND RISK FACTOR TO ACUTE MYOCARDIAL ISCHAEMIA IN CHILDREN WITH SICKLE CELL ANAEMIA

Introduction: Sickle cell anaemia (SCA) is a genetic disorder of haemoglobin synthesis with multi-organ manifestations. Myocardial ischaemia (MI) and infarction as a result of sickling are not commonly reported, often overshadowed by the more dramatic presentation of musculoskeletal pain. Studies have postulated that sudden deaths during vaso-occlusive crisis (VOC) may be secondary to the arrhythmogenic effect of severe MI. Aim: This study compared the prevalence of MI and associated risk factor in children with SCA aged 6 months to 18 years in VOC and steady state at the Lagos University Teaching Hospital using both cardiac troponin T (cTnT) and electrocardiography (ECG) as recommended by the fourth universal definition of MI (2018). Methodology: A cross-sectional comparative study conducted over 10months (March and December 2019). The participants were 250 children (125 age and gender-matched children with SCA in VOC and steady state respectively). Informed consent was obtained from the parents or caregivers while assent was obtained from children 10 years and above. Socio-demographic data and relevant history were obtained using an interviewer-administered questionnaire. Targeted clinical examination with focus on the cardiovascular system was done. All study participants had ECG performed and blood samples taken for cTnT, full blood count, electrolyte, urea, and creatinine. Myocardial ischaemia was defined as cTnT level greater than 100ng/L which is the 99th percentile and abnormal ECG findings indicative of MI (wide Q wave, ST-segment elevation or prolonged QT interval corrected for heart rate with accompanying Q wave abnormalities). Statistical package for social sciences (SPSS) software version 20 was used for analysis, statistical association was declared significant if the p-value was <0.05. Results: The prevalence of MI using cTnT alone in children with SCA in VOC and steady state was 42.4% (53) and 23.2% (29) respectively while with ECG alone, the prevalence of MI in children with SCA in VOC and steady state was 40.8% (51) and 20.8% (26) respectively. The prevalence of MI using both cTnT and ECG in children with SCA in VOC and steady state was 38.4% and 20% respectively and this was statistically significant (p-valve 0.001). In relation to VOC, the mean age (10.0±4.1), mean WBC (20,131.2±7,268.0), mean platelet count (461,208.0±143,956.8) and pain score of children with MI was significantly higher compared to those without MI. Among the steady state children, higher mean age (11.6±3.5), lower mean PCV (22.3±3.7) and higher mean platelet count (446,240.0±140,841.0) was significant in children in steady state with MI compared to those without MI. Furthermore, on multivariate analysis, the mean age & mean platelet count; mean age & low PCV; were significantly associated with MI in children with VOC and steady state respectively. The older age group in both study participants had a higher prevalence of MI. Combining both cTnT and ECG in the diagnosis of MI gave similar prevalence compared to using either cTnT or ECG alone. Conclusion: Myocardial ischaemia (MI) is prevalent in children with SCA. Children with SCA should routinely be screened for MI during VOC and steady state especially adolescents with SCA for early intervention.

Computed tomography angiography in anomalous left coronary artery from pulmonary artery: a case series

Anomalous left coronary artery from pulmonary artery (ALCAPA) is a rare congenital anomaly with a high rate of mortality in first year of life. It is one of the most common causes of cardiomyopathy and myocardial ischemia in children. In the present scenario, computed tomography (CT) coronary angiography is sufficient for the diagnosis of ALCAPA, eliminating the need of invasive angiography. CT coronary angiography performed in infants with suspicion of ALCAPA is technically challenging in terms of acquisition techniques, radiation protection and diagnostic interpretation. In this case series, we present five cases of ALCAPA diagnosed on CT coronary angiography. CT coronary angiography was able to delineate the anomalous origin of left coronary artery (LCA) from pulmonary artery in all cases. Anomalous LCA was noted to arise from posterior pulmonary sinus of pulmonary trunk in four cases and main pulmonary artery in one case. CT angiography also identified the extent of inter-coronary collateral vessels, left ventricular dysfunction and signs of pulmonary hypertension.

Clinical Utilities of Electrocardiography in the Diagnosis of Myocardial Ischemia in Children With Sickle Cell Anemia: Correlation With Serum Cardiac Troponin I.

Sickle cell anemia (SCA) is associated with recurrent vaso-occlusive crisis (VOC) and the risk of myocardial ischemia (MI). This study investigated the utility of electrocardiography (ECG) and cardiac troponin I (cTnI) in diagnosing MI during VOC. Children with SCA 5 to 15 years of age in VOC (patients) and age-matched and sex-matched steady-state controls were studied. Their ECG and cTnI levels were measured at contact and after 4 to 6 weeks. One hundred eighty-six children (93 patients and 93 controls) were studied. The mean (SD) ages of the patients and controls were 8.8 (3.2) and 9.0 (3.1) years, respectively. The mean MI score was significantly higher for the patients, 1.7 (1.2), than the controls, 1.3 (1.0), P=0.002. A significantly higher proportion of the patients, 18 (19.4%), also had significant ischemia compared with the controls, 8 (8.6%), P=0.016. The median (interquartile range) serum cTnI level was significantly higher in the patients than the controls, P=0.006. All 7 of the patients with elevated cTnI had VOC. No significant correlation was found between MI score and cTnI in both groups. cTnI is elevated and ECG features of MI worsen during VOC. Longitudinal studies to investigate their evolvement over time are advocated.

Preclinical Coronary Artery Anomalies and Silent Myocardial Ischemia in Children: How Can We Identify the Potentially Life-Threatening Conditions?

Preclinical Coronary Artery Anomalies and Silent Myocardial Ischemia in Children: How Can We Identify the Potentially Life-Threatening Conditions?

Prognostic Significance of Myocardial Ischemia Detected by Single-Photon Emission Computed Tomography in Children with Hypertrophic Cardiomyopathy

Myocardial ischemia caused by microvascular dysfunction is an important pathophysiologic component of hypertrophic cardiomyopathy (HCM), promoting myocardial fibrosis, adverse left ventricular remodeling, and impacting on clinical course and outcome in HCM patients. The aim of study was to assess the prevalence and clinical significance of myocardial ischemia in children with HCM using 99mTc-MIBI single-photon emission computed tomography (SPECT). Ninety-one children with HCM, median age 13.6 years, underwent SPECT evaluation from 2006 to 2017. Imaging was performed at rest and after maximal exercise. Myocardial perfusion defects were identified in 70 children (76.9%; group I), median age 13.8 years. Fixed perfusion defects were evident in 22 of them, while reversible at rest in 48. In 21 children (23.1%; group II), median age 11 years, myocardial perfusion defects were not detected. Patient demographics, echocardiography, resting electrocardiogram (ECG), 24-h Holter ECG, myocardial fibrosis in cardiovascular magnetic resonance imaging, and cardiovascular events were analyzed and compared between the groups. During follow-up at a median of 8.3 years in children with myocardial ischemia, clinical endpoints occurred more often (47 vs. 5; p = 0.02) and more patients reached a clinical endpoint (28 [40%] vs. 3 [14.3%]; p = 0.036). In children with myocardial ischemia, myocardial fibrosis was observed with greater frequency. Myocardial perfusion defects may reflect an ischemic process which (1) affects the clinical manifestations and (2) is an important predictor of adverse clinical events and risk of death in children with HCM. Myocardial ischemia in HCM patients frequently correlates with myocardial fibrosis.

Review: surgical treatment of giant coronary aneurysms in pediatric patients with Kawasaki disease.

In Kawasaki disease (KD), giant coronary aneurysms in the proximal segments of the coronary arteries have long been among the serious complications associated with acute myocardial infarction. To treat myocardial ischemia in children, Kitamura et al. first performed coronary artery bypass grafting in a pediatric patient using an autologous saphenous vein. In the early 1980s, they began to use the internal thoracic artery (ITA) as a bypass graft to the left anterior descending artery, which later was proven to improve long-term life expectancy with its favorable long-term patency, as well as growth potential. Thus, the excellent characteristics of the ITA have come to be widely known among pediatric cardiac surgeons, and a growing number of coronary bypass surgery procedures using the ITA are now being performed worldwide. Although a longer follow-up with more patients is necessary, downsizing reconstructive procedure may be a treatment of choice for giant aneurysms of non-LAD territories to improve coronary circulation. The efficacy of surgical treatment for giant coronary aneurysms in pediatric patients with Kawasaki disease is now well established. Pediatric coronary artery bypass grafting using the ITA, either single or bilateral, can be safe not only for patients with Kawasaki coronary disease but also for infants with congenital coronary lesions.

Abstract 12511: Exercise Stress Test and Myocardial Perfusion Imaging Have Limited Diagnostic Reliability in Detecting Coronary Abnormalities in Children After Arterial Switch Operation for Transposition of the Great Arteries

Background: Exercise stress test (EST) and myocardial perfusion imaging (MPI) are common non-invasive modalities to screen for occult myocardial ischemia, but their sensitivity and specificity in children are unknown. Hypothesis: EST and MPI have limited sensitivity and specificity in detecting occult myocardial ischemia in children. Patients and Methods: We retrospectively reviewed EST, MPI, and coronary angiogram in asymptomatic patients after arterial switch operation (ASO) for d-transposition of the great arteries (TGA) and examined the sensitivity and specificity of EST/MPI in detecting coronary abnormalities. Positive ECG findings for exercise-induced ischemia included ST-T depression &gt; 2mm and exercise-induced ventricular ectopies. Positive MPI is defined as a perfusion defect. Data are shown as mean ± SD. Results: Thirty asymptomatic patients (20 male/10 female; 23 with intact ventricular septum and 7 with ventricular septal defect; ages 12.5 ± 4.4 years) had EST and 26 had simultaneous MPI. Respiratory quotient was 1.11 ± 0.07 and maximum oxygen consumption was 80.7 ± 15.0% predicted, suggesting mildly diminished aerobic fitness level. There was no exercise-induced arrhythmia. Twenty two patients had coronary angiogram (Table 1). Four patients with positive EST and/or MPI were confirmed to have coronary abnormalities by coronary angiogram, whereas 4 patients revealed variable degree of coronary obstruction despite negative EST/MPI including 1 patient who later developed life-threatening ventricular fibrillation. Three patients with positive EST or MPI showed no coronary abnormalities. Conclusions: A combination of EST and MPI has low sensitivity (50%; 4/8) and moderate specificity (79%; 11/14) in detecting coronary abnormalities after ASO. Thus, we recommend performing coronary angiography or equivalent coronary investigation in addition to EST/MPI in children after ASO to detect coronary abnormalities and myocardial ischemia.

Heart type fatty acid binding protein, a marker of myocardial ischemia in children with epilepsy

To evaluate ictal serum levels of heart type fatty acid binding protein (H-FABP) in children with intractable epilepsy as a marker of cardiac ischemia in comparison to their levels in the interictal period and that of controls. The study included 23 seizure episodes recorded in 14 patients with intractable seizures. Serum levels of H-FABP in the ictal and interictal periods were done as well as simultaneous electrocardiogram, Holter and video electroencephalography recordings with evaluation of changes in the heart rate (HR), and HR variability parameters. Levels of H-FABP were higher in the patients' group whether in the ictal or interictal periods compared to the control group. However, levels were not significantly different in the ictal period compared to the interictal one. Ictal tachycardia was recorded in 95% and bradycardia in 5% of the studied seizures episodes. Premature atrial and ventricular contractions were recorded in the 1 st postictal hour of 8.7% and 30.4% of the recorded seizures, respectively. Interictal values showed significant increase minutes before the onset of the seizures and remained high 2 hours postictally. All time domain HR variability parameters were lower in the patients' group. Our results showed significant increase in the serum levels of H-FABP in our patients' group, which might suggest a degree of myocardial ischemia even in asymptomatic patients. Though bradycardia, prolonged QTc and arrhythmic changes were reported in few cases, the importance of the results warrants studying those changes at least in patients with refractory seizures.

Symptomatic myocardial bridge induced acute myocardial ischemia in children: a case report and literature review

A child case of acute myocardial ischemia induced by symptomatic myocardial bridge (SMB) was reported and relevant literatures were reviewed in this article. The case and literatures indicate that myocardial bridge is a rare congenital coronary artery anomaly in children. The pathogenesis may be related to stenosis, spasm, arteriosclerosis of coronary artery because of myocardial bridge compression during systole. Clinical manifestations include chest pain, malignant arrhythmia, syncope, cardiac arrest and myocardial infarction. The diagnosis of myocardial bridge is based on cardiac imaging. SMB patients should be first treated with β-adrenergic; if ineffective, surgical treatment or implantable automated cardiac defibrillator should be chosen. The patients complicated with hypertrophic cardiomyopathy have worse conditions with high mortality. Key words: Myocardial bridge; Myocardial ischemia

Stress Echocardiography: A Useful Tool for Children With Aortic Stenosis

The development of echocardiographic ventricular wall motion abnormalities and ST segment changes with exercise may enhance the detection of myocardial ischemia in children with aortic valve stenosis (AS). This study aimed to assess the relationship between the exercise wall motion index (WMIe), ST segment depression (STd), and overall functionality in asymptomatic children with isolated AS. A prospective interpretation of collected stress echocardiographic images was performed. The 98 children who met the inclusion criteria had a mean age of 12.8 years and a male/female ratio of 4/1. Group 1 (mild AS) was composed of 70 children, and group 2 (moderate or severe AS) was composed of 28 children. Abnormal WMIe was seen in 8 patients (5 in group 1 and 3 in group 2), and significant STd was observed in 13 children (3 in group 1 and 10 in group 2). Four (50 %) of the eight patients with abnormal WMIe also had significant STd. Severity of stenosis was associated with STd (odds ratio [OR], 12.0; 95 % CI 3.0-49.0), logistic regression). A significant association also existed between abnormal WMIe and STd (OR, 9.0; 95 % CI 1.9-42.0, logistic regression). Exercise duration was significantly shorter in group 2 (12 ± 4.52 min) than in group 1 (13 ± 5.28 min) (p = 0.02, analysis of covariance). The appearance of wall motion abnormalities and STd during exercise may be helpful in detecting inducible, functionally important myocardial ischemia in asymptomatic children with AS. Stress echocardiography may be a useful adjunct to more traditional exercise testing in risk stratifying asymptomatic children with AS.

Myocardial ischaemia in sickle cell anaemia: evaluation using a new scoring system

Sickle cell anaemia (SCA) is associated with recurrent multi-organ ischaemia and infarction. Myocardial ischaemia (MI) and infarction are increasingly recognised as features of SCA. The prevalence and severity of MI in children with SCA is not known. To evaluate the usefulness of a new scoring system based on the standard surface electrocardiogram (ECG) in determining the prevalence and severity of MI in children with SCA. MI prevalence and scores derived from standard surface ECGs of 35 children with SCA aged 3-18 years who presented consecutively during 38 episodes of vaso-occlusive crisis (VOC) were compared with those of 40 age- and sex-matched SCA patients in the steady state and 40 anaemic non-SCA patients. In SCA subjects with VOC, ECG was repeated approximately 1 week and 4-8 weeks post crisis and the respective MI scores were compared with their intra-crisis ECG and those of the two other groups. Mean (SD) MI scores were significantly higher during vaso-occlusive crises [1·82 (0·20)] compared with the steady state [1·15 (0·15)] and non-SCA anaemic controls [1·13 (0·21)], p = 0·017. SCA patients in crisis were 5·5 (1·20-13·99) times more likely to have MI compared with non-SCA anaemic controls (p = 0·025). They were also 3·66 (1·05-12·74, p = 0·042) and 7·58 (1·31-43·92, p = 0·024) times more likely to have mild and significant MI, respectively. MI scores derived from the post-crisis ECGs were similar to those of steady-state SCA patients. ECG changes consistent with MI are common in children with SCA, especially during vaso-occlusive crises. Our proposed MI scoring system could be a useful screening tool for early detection of significant MI during crises, facilitating early institution of intervention. Further studies are needed to determine the specificity of the observed changes and to validate the proposed screening tool.

Anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) in a newborn

A 5-day-old child was referred to the department of cardiology for bradycardia without any other cardiac symptoms. ECG was normal. Cardiac echography demonstrated a reverse flow inside the interventricular branch of the left coronary artery suggesting ALCAPA. ECG-gated multidetector CT angiography, with oblique axial view (a) and 3-D volume-rendered images (b), confirmed the diagnosis of ALCAPA (DLP=99 mGy-cm) (Fig. 1). Reimplantation of the left coronary artery into the aorta was performed promptly and with success. ALCAPA is a rare congenital anomaly but is one of the most common causes of myocardial ischemia in children [1]. Usually, symptoms occur around 8 weeks of life. If untreated, most patients will die within the first year of life. Cardiac echography alone permits the diagnosis of ALCAPA. Nevertheless, ECG-gated multidetector CT angiography can be used instead of conventional angiography to clarify the anatomy or confirm an unclear diagnosis [2]. In neonates, early surgical correction allows improvement of ventricular function.

Prinzmetal Angina in an Adolescent

A previously asymptomatic 17-year-old male athlete presented with acute onset of left-sided chest pain that awakened him from sleep. The pain was described as “crushing,” radiated to the left arm and jaw, and associated with diaphoresis. He was evaluated in the emergency department of our hospital and was found to have an abnormal ECG with ST-segment elevation in the anterolateral leads (Figure 1A). Initial troponin I and creatine kinase-MB (CK-MB) were elevated, 5.7 ng/mL (0 …

Myocardial ischaemia in children with sickle cell disease

Background: The heart may be involved in children affected with sickle cell disease (SCD) via several mechanisms. Principally, chronic anaemia increases cardiac output and may cause left ventricular enlargement and...

Intraoperative Myocardial Ischemia Recognized by Transesophageal Echocardiography Monitoring in the Pediatric Population: A Report of 3 Cases

We used continuous intraoperative transesophageal echocardiography (TEE) monitoring to detect intraoperative myocardial ischemia in children after they had been weaned from cardiopulmonary bypass for cardiac surgery. Three pediatric patients are described here to illustrate the usefulness of such TEE monitoring in surgical procedures involving coronary arteries. The indications for intraoperative TEE monitoring and a simplified scheme for immediate qualitative interpretation are discussed. (J Am Soc Echocardiogr 2000;13:615-8.)

Myocardial ischaemia in children with isolated ventricular non-compaction.

Isolated ventricular non-compaction is a rare congenital cardiomyopathy with a high morbidity and mortality due to malignant arrhythmias and pump failure. Areas affected by non-compaction are characterized by increased trabecularization and deep inter-trabecular spaces. We hypothesized perfusion defects in these areas and performed positron emission tomography to evaluate the myocardial perfusion in non-compacted areas. Five children (age 10-14 years) with isolated ventricular non-compaction underwent positron emission tomography using N-13-ammonia as flow marker and intravenous dipyridamole for stress testing. Myocardial blood flow was quantified using the positron emission tomography time-activity curves in non-compacted areas and normal myocardium, which were diagnosed by echocardiography, magnetic resonance imaging, and angiography. Coronary angiography, performed in two children with extensive forms of left ventricular non-compaction, demonstrated normal coronary arteries. Myocardial blood flow measurements at rest and after dipyridamole application demonstrated 16-33% and 32-57% perfusion impairment, respectively, in non-compacted areas compared to normal myocardium. Areas of restricted myocardial perfusion corresponded well to the non-compacted areas, defined echographically and by magnetic resonance imaging. Positron emission tomography demonstrates restricted myocardial perfusion and decreased flow reserve in areas of ventricular non-compaction in children. The myocardial perfusion defects in non-compacted areas may be the cause of myocardial damage and possibly form the basis of arrhythmias and pump failure.

Mechanisms of Myocardial Ischemia in Children Receiving β-Agonist Therapy for Asthma

Mechanisms of Myocardial Ischemia in Children Receiving β-Agonist Therapy for Asthma

Sudden Death in Children with Hypertrophic Cardiomyopathy

Source: Yetman A, McCrindle B, et al. Myocardial bridging in children with hypertrophic cardiomyopathy—a risk factor for sudden death. N Engl J Med. 1998;339:1201–1209.Sudden death in children with hypertrophic cardiomyopathy is suspected to be due to myocardial ischemia. In a retrospective study, Yetman et al reviewed coronary artery angiograms in 36 children (age 7.1 ± 5.8 years) with hypertrophic cardiomyopathy. Angiographic findings were compared to history before and after angiography and clinical evidence of myocardial ischemia on ECG, echocardiograms, exercise testing, 24-hour Holter monitoring, and Thallium perfusion testing.The prevalence of myocardial bridging, resulting in systolic and diastolic compression of the left anterior coronary artery by abnormal bands of myocardium, was increased in 10 of 36 of children studied. Myocardial bridging was significantly associated with a history of chest pain (p= 0.04), cardiac arrest (p=0.004), and ventricular tachycardia (p<0.001). Patients with bridging were more likely to exhibit an abnormal fall in blood pressure during exercise (p<0.001) and a significantly shorter mean duration of exercise tolerance (p=0.008). Kaplan-Meier actuarial analysis demonstrated a higher probability of sudden death in patients with bridging compared to those who had no coronary artery compression (p=0.004). Three patients who had the abnormal bands of myocardium divided surgically had resolution of signs and symptoms of ischemia. The authors conclude that myocardial ischemia in children with hypertrophic cardiomyopathy may be due to myocardial bridging and may be one of the primary causes of sudden death in these patients.Although hypertrophic cardiomyopathy (also known as IHSS) is relatively rare, it is the most common cause of sudden death in adolescents and young adults. It is usually familial and often asymptomatic. Among athletes who die suddenly during exercise, hypertrophic cardiomyopathy is the most common identifiable cause.1 Predictors of sudden death in IHSS, primarily derived from studies in adults, include a history of sudden death in family members, ventricular tachycardia on Holter monitor, and a history of syncope. With the exception of Amiodarone (which is used for ventricular arrhythmias), neither surgical nor medical interventions have been shown to prevent sudden, unexpected death.It has long been thought that either myocardial ischemia resulting in myocardial infarction or lethal arrhythmia was the final common pathway leading to death.2 In this report, Yetman et al describe a small series of patients with hypertrophic cardiomyopathy who have an unusually high prevalence of “myocardial bridging” on coronary angiography. The authors found a strong association of myocardial bridging with other variables related to myocardial ischemia and sudden death, including chest pain, prior cardiac arrest, ventricular tachycardia, and evidence of ischemia on exercise testing. This association is provocative because surgical division of the abnormal bridges of myocardium causing compression of coronary arteries could effectively reduce ischemia and the risk of sudden death. Unfortunately, the small size of the study (a common problem in the study of any uncommon disease) did not allow an assessment of a potential surgical cure on the subsequent occurrence of sudden death. Clearly a multi-center prospective study of children with hypertrophic cardiomyopathy is needed to have adequate statistical power to assess the predictive value of myocardial bridging for sudden death and the potential benefit of surgery. Nonetheless, given the strong association with other factors for sudden death, the search for myocardial bridging by coronary angiography certainly appears to be warranted in all children with severe hypertrophic cardiomyopathy, particularly those with other risk factors for sudden unexpected death.

Evaluation of myocardial ischemia in Kawasaki disease by dobutamine stress signal-averaged ventricular late potentials.

To determine the possibility of diagnosing myocardial ischemia from signal-averaged electrocardiographic late potentials (LPs) in patients with Kawasaki disease. Dobutamine stress LPs were obtained in 85 children with a history of Kawasaki disease (48 without coronary artery lesions, 19 with coronary artery lesions without myocardial ischemia, and 18 with myocardial ischemia). The infusion of dobutamine was started at 5 micrograms/kg/min, increased to 30 micrograms/kg/min. The presence of LPs was determined by the filtered QRS duration, the root mean square voltage during the last 40 ms, and the duration of the signal under 40 microV. Among the children without coronary lesions, LPs were detected in 4.2% at rest and in 2.1% with dobutamine stress. Among the group with coronary lesions but without ischemia, LPs were found in 5.3% at rest and in 5.3% with stress. In the group with ischemia, LPs were present in 44.4% at rest and in 77.8% with stress. The sensitivity for myocardial ischemia was 72.7% at rest and 87.5% with stress (p < 0.05), and the specificity was 86.5% at rest and 94.2% with stress. LPs associated with dobutamine stress testing are useful for identifying myocardial ischemia in children with Kawasaki disease, especially in those who cannot tolerate testing involving physical exercise.